Implementation Support for Serious Reportable Events (SRE)/Provider Preventable Conditions (PPC) Payment Policy

Client Description

The client, a leading health insurer for a Medicaid Managed Care health plan in the Northeast serving over 250,000 members.

Challenge

The organization’s SRE/PPC Steering Committee had been convening for almost a year and needed to address some remaining challenges in terms of clarifying policies and ensuring stakeholder understanding and implementation of Present on Admission (POA) and SRE reporting requirements.  

Technology

This project involved defining business requirements to support the revised SRE/PPC payment policy specification for hospital claims to include POA indicators with most diagnoses, validating required POA claim adjustments and meet quality and regulatory reporting requirements. Several custom solutions were implemented within the legacy systems to automate processing and reporting solutions.

Ninestone’s Approach

Ninestone was brought in to complete the refinement of the SRE/PPC Payment Policy and coordinate the implementation of the updated policy.   This included provider notifications, operational policies/procedures, training materials as well as the technical solution.  To accomplish this, we participated in Steering Committee meetings and completed on-the-ground research activities and facilitated ad hoc team meetings.

Results

Ninestone was able to guide the implementation of the revised SRE/PPC payment policy in a timely manner, while additionally highlighting and facilitating several discussions to address post-implementation issues.  We are also providing support for a post-implementation internal audit of the process.